Utilization Review Specialist

Summary

We are seeking an experienced Utilization Management Consultant to establish and optimize our Utilization Management process in Manila, Philippines. The consultant will design and implement comprehensive UM procedures, segregate roles and responsibilities, build training programs for nurses and team managers, and develop onboarding processes for new US clients.

Requirements

• Bachelor’s or Master’s degree in Nursing, Healthcare Administration, or a related field
• Minimum of 5 years of experience in Utilization Management, Utilization Review, and clinical review processes
• Proven experience in process development and team management
• Excellent communication and training skills
• Strong understanding of US healthcare regulations and compliance standards

Responsibilities

• Design and implement a comprehensive Utilization Management process tailored to hospital and clinical review needs
• Develop standardized protocols for utilization review, clinical reviews, and medical necessity appeals
• Clearly define and segregate roles and responsibilities within the UM team
• Create detailed job descriptions for UM nurses, team managers, and other key roles
• Develop and conduct training programs for UM nurses and team managers
• Design an efficient onboarding process for new US clients
• Coordinate with the US-based team to ensure seamless integration of new clients into the UM system
• Establish metrics for evaluating the effectiveness of the UM process

Benefits

Competitive salary based on experience and qualifications